Disability Representative Sr

About the Role

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

Responsibilities

• Makes independent claim determinations to approve complex disability claims or recommends denial to team lead based on the disability plan.
• Reviews and analyzes complex medical information (e.g., attending physician statements, office notes, operative reports) to determine disability as defined by the plan.
• Oversees additional facets of complex claims, including comorbidities, concurrent plans, complex ADA accommodations, and claims outside typical guidelines.
• Utilizes clinical resources (e.g., duration guidelines, in-house clinicians) in case assessment.
• Determines benefits due, makes timely payments/approvals, and adjusts for offsets like workers’ compensation and SSDI.
• Informs claimants of required documentation, time frames, payment details, and claim status via phone, written correspondence, or claims system.
• Communicates with providers to set return-to-work expectations.
• Medically manages complex claims, ensuring compliance with duration guidelines and plan provisions.
• Coordinates investigative efforts, thoroughly reviews contested claims, and negotiates return to work with or without accommodations.
• Evaluates and arranges referrals to outside vendors (e.g., physician reviews, surveillance, independent medical evaluations).
• Refers cases to team lead and clinical case management for additional review when needed.
• Maintains professional client relationships and provides excellent customer service.
• Meets organizational quality program requirements.

Qualifications

• Education & Licensing:
  • High School diploma or GED required.
  • Bachelor's degree preferred.
  • State certification or licensing in statutory leaves preferred or required based on state regulations.
• Experience:
  • Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.
• Skills & Knowledge:
  • Knowledge of ERISA, offsets/deductions, disability duration, medical management, and SSDI procedures.
  • Understanding of state and federal FMLA regulations.
  • Working knowledge of medical terminology and duration management.
  • Excellent oral and written communication, including presentation skills.
  • Proficient in Microsoft Office and computer skills.
  • Analytical, interpretive, and critical thinking abilities.
  • Strong organizational and multitasking skills.
  • Ability to work in a team environment and manage ambiguity.
  • Effective decision-making and negotiation skills.

Work Environment

When applicable, reasonable accommodations will be considered. Requires clear thinking, excellent judgment, problem-solving, and discretion. Ability to handle stress, multiple priorities, and deadlines. Physical requirements include sitting for extended periods and using a computer/phone system. Travel as required. Auditory/visual abilities necessary for communication.